Review Question - QID 103024

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Prostate Cancer Treatment Treatment dependent on pathological features, metastasis, and the patient's life expectancy QID: 103024 (M3.ON.12.1)

QID 103024 (Type "103024" in App Search)

A 97-year-old man visits the urology clinic 5 days after experiencing urinary retention at an emergency department visit. The patient has a history of hypertension, type II diabetes mellitus, stroke, dyslipidemia, a past myocardial infarction, and severe osteoarthritis in his right hip. He is not compliant with his medications and his multiple comorbidities are poorly managed. In the hospital, the patient’s urinary retention was treated with Foley catheterization. At clinic, the patient’s serum-specific prostate-specific antigen (PSA) is 6.0 ng/mL (normal is < 4 ng/mL). Digital rectal examination (DRE) demonstrates a nontender prostate with several rock hard nodules. The patient's Foley is removed and he is able to urinate on his own. Which is the most appropriate next step in management?

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CT abdomen and pelvis

0/7

Cystourethroscopy

0/7

Transrectal prostate biopsy

86%

6/7

Reassurance

14%

1/7

Repeat PSA test

0/7

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A transient elevation in PSA will often decrease after a period of 2-6 weeks once the underlying cause has resolved. This elderly patient should not be screened for prostate cancer given his age and multiple comorbidities despite his PSA and nodular prostate.

PSA is a serine protease that liquefies semen after ejaculation. PSA has a diagnostic role in prostate cancer (though is not routinely ordered) and is also used to measure the response to cancer treatment. However, PSA is also commonly elevated in benign prostatic hyperplasia, which is common among elderly men. Transient PSA elevations can occur due to urinary retention, prostatic inflammation, as well as cystoscopy. PSA screening and digital rectal exam are no longer recommended as routine screening for prostate cancer. Similarly, the course of prostate cancer is often long and work up for elderly or critically ill patients is not indicated as they are likely to die from natural causes or other medical issues when compared to the slow course of prostate cancer.

Incorrect Answers:
Answer 1: CT abdomen and pelvis is used to evaluate for pelvic and retroperitoneal lymph nodes in men with prostate cancer. This patient has not yet been diagnosed with prostate cancer.

Answer 2: Cystourethroscopy can be used to assess for obstruction of the bladder. The patient no longer has symptoms of urinary retention and there is not a concern for bladder cancer which presents with painless hematuria.

Answer 3: Transrectal prostate biopsy would be indicated if the patient had a suspicious digital rectal exam (rock-hard nodules) and was younger with less medical comorbidities. This patient’s age and other medical problems make him a poor candidate for invasive testing and procedures that may have no impact on his quality of life.

Answer 5: Repeat PSA test at a later time is incorrect as it would not change management. In this elderly patient with multiple comorbidities, even if the level remains elevated, it would not change management.

Bullet Summary:
Prostate cancer should not be worked up in elderly patients with multiple medical comorbidities given that treatment of their prostate cancer is not likely to improve morbidity or mortality.

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